Open Reduction and Internal Fixation of Intra-articular Distal Femur Fractures

29 Open Reduction and Internal Fixation of Intra-articular Distal Femur Fractures


Andrew L. Rosen


Patient Presentation



  1. History of trauma to the knee
  2. Bimodal distribution of patients—very young and elderly1

Indications



  1. Displacement of articular surface fragments
  2. Open fractures
  3. Vascular injury associated
  4. Bilateral femur fractures
  5. Ipsilateral tibial fractures

Relative Contraindications



  1. Nonambulatory patient
  2. Severe osteopenia

Physical Examination



  1. Painful, swollen knee
  2. Assess skin integrity.
  3. Assess neurovascular status.

Diagnostic Tests



  1. Anteroposterior and lateral radiographs
  2. Computed tomography (CT) scan with three-dimensional (3D) reconstruction can be helpful in assessing fragments.

Special Considerations



  1. Compression screw systems are strong constructs, suited for proximal fractures with low amounts of comminution.
  2. Precontoured condylar plates are better suited for low transverse and comminuted fractures.
  3. Locking plates preferable with osteopenic bone2

Preoperative Planning and Timing of Surgery



  1. Open fractures are treated emergently.
  2. Closed fractures can be treated as soon as operative time is available, and medical evaluation is complete.
  3. Tibial pin traction can be initiated upon arrival to maintain length of fracture; may defer it if the bone is very osteoporotic.

Special Instruments



  1. Large bone reducing clamps—generally available on pelvic reconstruction sets
  2. Kirschner wires (K-wires) for provisional reductions
  3. Condylar plates (standard or locking) or angled 95-degree compression screw plate
  4. 7.3-mm cannulated screws
  5. Intraoperative digital fluoroscopy
  6. Bone graft: iliac crest autograft or cancellous allograft can be used
  7. Femoral distractor to aid in reduction

Anesthesia


Options are general anesthesia or epidural.


Patient and Equipment Positions



  1. Supine on radiolucent table
  2. “Bump” padding placed under ipsilateral hip
  3. Leg and iliac crest prepped and draped
  4. Sterile tourniquet applied, inflated after leg exsanguination
  5. Large sterile bump placed under thigh to flex knee above contralateral knee

Surgical Procedure


Conventional



  1. Anterolateral approach most common3
  2. Incision along lateral aspect of distal leg to point between distal pole of patella and tibial tubercle
  3. Vastus lateralis reflected anteriorly from lateral intermuscular septum
  4. Lateral joint capsule incised to visualize articular surface
  5. If intraarticular fracture, articular surface fragments reduced, held in place using large bone tenaculums, provisional K-wires

Transarticular, Minimally Invasive



  1. Affords better joint visualization4
  2. Midline incision with lateral parapatellar approach
  3. Joint exposed, fracture examined
  4. Plate must be applied laterally beneath the vastus lateralis
  5. Proximal screws applied percutaneously, guides available for some systems

PRECONTOURED CONDYLAR BUTTRESS PLATE TECHNIQUE (STANDARD OR LOCKING)


  1. Plate positioned directly over lateral of femoral condyle.
  2. Reduction of proximal to distal fragment performed with plate applied and clamps on bone, attention paid to avoiding varus angulation. Large pelvic reduction forceps can be used to help reduction as well.
  3. Femoral distractor can be applied if difficulty in obtaining length is recognized.
  4. Nonlocking screws are inserted first into proximal and distal fragments to approximate plate-to-bone and compressing distal fragments. Remaining screws are placed (locking or standard).5

COMPRESSION-SCREW PLATE TECHNIQUE6


  1. Articular surface reconstructed if necessary with parallel 7.3-mm cannulated screws inserted from lateral to medial to compress sagittal fracture lines. Care is taken to place in position to allow subsequent plate placement.
  2. Guidewire placed parallel to condyles, 2 cm proximal to joint line, in the anterior one-third of the distal femur from lateral to medial. Wire positioned perpendicular to the cortex, ~10 degrees from the posterior condylar axis.
  3. Cannulated triple reamer used to create path for screw around pin
  4. Screw length measured
  5. Screw inserted
  6. Burr or gouge used to trim bone proximally adjacent to screw to allow flush placement of plate
  7. 95-degree plate inserted over distal screw, reduced to bone with clamps
  8. Reduction performed of proximal fragment to distal fragment. Plate applied to proximal fragment with screws.

Tips and Pearls



  1. Intraoperative fluoroscopy used to assess hardware placement, screw lengths
  2. Intraoperative plain film radiographs better for assessing fracture alignment and reduction
  3. Care should be taken to keep plate in proper position proximally. Avoid anterior rotation of plate compromising fixation of proximal screws.
  4. Consider bone grafting for many fractures

Dressings, Braces, Splints, and Casts



  1. Bledsoe brace applied postoperatively
  2. Progressive, protected range of motion started early if confident of fixation stability

Pitfalls and Complications



  1. Osteopenic bone can compromise fracture fixation strength. Use of locking plates, and/or supplementation with bone cement can enhance stability7

Postoperative Care



  1. Non-weight bearing maintained for 6 to 8 weeks.
  2. Radiographs performed at regular intervals to assess fracture alignment and healing.

References


1. Butt MS, Krikler SJ, Ali MS. Displaced fractures of the distal femur in elderly patients. Operative versus non-operative treatment. J Bone Joint Surg Br 1996; 78:110–114


2. Schutz M, Muller M, Krettek C, et al. Minimally invasive fracture stabilization of distal femoral fractures with the LISS: a prospective multicenter study. Results of a clinical study with special emphasis on difficult cases. Injury 2001;32(suppl 3):SC48–SC54


3. Browner BD. Skeletal Trauma: Basic Science, Management, and Reconstruction. Philadelphia: Saunders, 2003


4. Kregor PJ. Distal femur fractures with complex articular involvement: management by articular exposure and submuscular fixation. Orthop Clin North Am 2002;33:153–175, ix


5. Kolb W, Guhlmann H, Friedel R, Nestmann H. [Fixation of periprosthetic femur fractures with the less invasive stabilization system (LISS)—a new minimally invasive treatment with locked fixed-angle screws]. Zentralbl Chir 2003;128:53–59


6. Rockwood CA, Green DP. Rockwood and Green’s Fractures in Adults. Philadelphia: Lippincott-Raven, 1996


7. Struhl S, Szporn MN, Cobelli NJ, Sadler AH. Cemented internal fixation for supracondylar femur fractures in osteoporotic patients. J Orthop Trauma 1990;4:151–157


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Aug 4, 2016 | Posted by in ORTHOPEDIC | Comments Off on Open Reduction and Internal Fixation of Intra-articular Distal Femur Fractures

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